Q&A:1. How feasible is collaboration between managed markets, commercial, government programs and Finance?

Successful collaboration will largely depend on the particular individuals involved. The key is for everyone to have an enterprise view.

2. Key questions to ask before investing and building an automated GTN system?

- What functionality is most important to your organization?- How much are you willing to invest?- When do you need the system to go live?3. How to accrue and forecast patient/ payer related items? What critical/essential information is required and what aspects you can’t afford to overlook.

Forecasting and accruals are typically based on past history with some adjustments where there are specific changes expected in the future. Having information to develop these adjustments is critical and could include: segment lives and expected trends, TRX data, formulary changes, legislation changes.

Wednesday, May 28, 2014

This June at IIR’s Healthcare Data Insights, Bob Gladden, Vice President for Decision Support and Informatics at CareSource will speak on a session titled “Taking a Persona-Centric, Not a Disease-Centric, Approach to Care Management & Engagement”. Session Info:The typical member management program entails profiling members based on their disease states without taking into account the patient as a whole. Beginning in the Fall of 2013, CareSource started using claims and enrollment data to segment their members into a specific persona, then began services to members based upon the persona in which they were identified. Learn how they build data driven personas and understand the results they’ve seen to date.

Q&A:

1. What does data driven decision-making mean to you?

To me it means that when possible, we eliminate the guess work component of decision-making. There will always be a component to decision making that is not quantitative, but that should be by choice, not because the data isn’t available in a format that can be incorporated into the decision-making process.2. How do data sets (EHR data, claims data, member feedback, etc.) to inform your business strategy?

As a Medicaid managed care organization, we use claims data extensively to help shape everything from care programs to business strategy. Ongoing, our strategy continues to be to augment the claims data view of our membership with other data sets that can enrich our view of our members, and help us to identify their needs at the earliest possible moment. As one example, we are currently working on a partnership with a state Health Department and a major university that will expand our view beyond claims data to include social/economic data.

3. In general, how difficult is it to get internal buy-in to build out programming that’s based on data?

Actually, at CareSource the difficulty has been to build out the data to support and enhance programs fast enough to keep up with the requests. Senior leadership here has for some time been asking for more data support to build all of their efforts. Having leadership asking for this support goes a long way toward the success of having an organization focus decision making on fact and less on hunches.4. How do you see your use of data evolving in the upcoming year? Are there new opportunities to use data to create more effective, innovative programming?

There are a number of changes that are coming. The most notable in health care is the provider base moving to electronic medical records. Many of these systems were first stood up just to meet requirements for enhanced reimbursement, but now the effort is to fully incorporate this information in work-flow and use it in a meaningful way. To that end, there are more changes coming that could even eliminate traditional claims as we know them today. It is all part of many exciting developments that will change how we all do business to deliver far more effective and higher quality care.

How and to what extent do various stakeholders bring value to the treatment of patients with cancer?

Bill:Well, I think that’s something that we really need to look at closer because there are a lot of discussions, obviously, about the level of healthcare expenditures and the increase and rate of rise and expenditures of care to treat patients with cancer. First of all, you look at providers and clearly their expertise, their acumen and their understanding is really about providing what the optimal treatment recommendations are for patients. Carrying out that treatment plan brings a lot of value to the system. And then you look at the manufacturers, the biopharma companies, the medical device companies and they bring innovative products to the market that address the many, many needs and unmet needs that still exist for the many different types of cancer specifically. And that’s critical. They bring value to patients directly. Then, you start to get down into other areas of the healthcare system that are more management operations oriented and you look at managed-care companies. They bring value in the sense that they help to organize the system. They pay the claims and the develop networks of clinicians to work with patients specifically. But, really, what I think we need to do is, as we expend resources to bring care ultimately to patients with cancer, we really need to take a closer look at, again, which components, which stakeholders bring actual value to the treatment of patients.

Rules and Regulations Apply:
• Registrants will receive 26% off the standard registration rates
• This offer only applies to passes purchased on Thursday, May 22, 2014 to Monday, May 26, 2014
• This offer only applies to online registration

*This offer cannot be retroactively applied on existing registrations nor combined with other offers, discounts or promotions. Offer only valid between May 22 - May 26, 2014.

Rules and Regulations Apply:
• This offer is only available for the Full Access (All 3 Days)
• This offer is not eligible for Main Conference Only (June 23-25)
• Registrants will receive 26% off the standard registration rate.
• This offer only applies to passes purchased on Thursday, May 22, 2014 to Monday, May 26, 2014
• This offer only applies to online registration

*This offer cannot be retroactively applied on existing registrations nor combined with other offers, discounts or promotions. Offer only valid between May 22 - May 26, 2014.

Rules and Regulations Apply:
• This offer is only available for the Full Access (All 3 Days)
• This offer is not eligible for Main Conference Only (July 21-23)
• Registrants will receive 26% off the standard registration rate.
• This offer only applies to online registration

*This offer cannot be retroactively applied on existing registrations nor combined with other offers, discounts or promotions. Offer only valid between May 22 - May 26, 2014.

Rules and Regulations Apply:
• Registrants will receive 26% off the standard registration rates
• This offer only applies to passes purchased on Thursday, May 22, 2014 to Monday, May 26, 2014
• This offer only applies to online registration

*This offer cannot be retroactively applied on existing registrations nor combined with other offers, discounts or promotions. Offer only valid between May 22 - May 26, 2014.

Wednesday, May 21, 2014

The recent debate over healthcare reforms has made one thing clear: unsustainable costs are leading to fundamental shifts in the way cancer care is delivered. There is a growing expectation that healthcare represents good "value".

As a stakeholder within the cancer care value chain many complex issues vie for your time and attention. You must simultaneously grasp the big picture, staying abreast of the changing oncology landscape, and keep focused on the day-to-day concerns that impact delivery of effective and efficient patient care. At IIR's Oncology Management Summit you will walk away with solutions to the most critical issues: cost, access to care, incorporating new technology, and meeting standards for patient-centered care. Oncology pioneers provide an understanding of the big picture, but also with practical, useful information to help you improve care now.

IIR's Annual Summit for Oncology Management is your 360° view of the cancer value chain; where stakeholders and influencers including payers, providers, hospital systems, leading cancer centers, and pharmaceutical executives convene to discuss how to control costs, increase quality, determine value and improve overall patient experience for cancer care.

Case Study: Chargeback Reserve Estimates and Methodology
• Reserve True-up methodology
• Developing point of sale accrual rates for products
• Various operational metrics used by accounting and FP&A departments to analyze and monitor reserve balances
• Using external channel data in our true up and monthly metrics analysis
• Picking an external inventory channel vendor and monitoring and maintaining the data received from the wholesalers; setting up wholesaler 852/867 fees
• Leading internal and external audit teams through the wing to wing chargeback process

Follow-up Chargeback Panel Discussion
• What are key complexities to the chargeback process and how are these managed?
• What are considerations for contractual renewal, reporting requirements and discounts between commercial and governmental customers?
• Process considerations for validation activities

1. How feasible is collaboration between managed markets, commercial, government programs and Finance?

Constant dialogue between departments is a necessity. From my an accounting point of view, we here at GE Life Sciences promote this through a variety of measures including:• Monthly GTN meetings with commercial, finance and accounting department leaders to discuss point of sale rates and operational results/ metrics;• Monthly GTN accrual meetings with commercial and government teams; • Commercial contract “workflows” that ensure the impact of new/ revised contracts are reviewed/approved by each of these groups;• Daily adhoc communications via email, phone etc. to ensure new issues are communicated to each group.

2. Key questions to ask before investing and building an automated GTN system?

Key questions would include:• Is this a global or US IT solution?• How is data integrity maintained? How can data be traced to the GL/ be audited?• How will the solution interact with our current systems?• Who are the report users? Do the reports meet their needs?

3. How to accrue and forecast patient/payer related items? What critical/essential information is required and what aspects you can’t afford to overlook.

Patient/ payer accruals is not really applicable for our distribution chain. Our products are diagnostic agents used by hospitals for various imaging scans.

How do you make data-driven decisions across the organization?Bob: It’s been an interesting journey that we’ve been on. I think we’ve been on this like a number of other companies. I’ve heard some references to how companies are dealing with this today in terms of how decisions are made. Are they made based on individuals having data and pouring through that and coming up with a solid answer? Or is it based on what they call in the industry “HIPPOs”, which simply translates into ‘highest paid person’s opinion’. Now, we have to be careful about calling people HIPPOs. That doesn’t tend to go over well. But, we are working towards certainly the value that those highest-paid individuals have – a lot of energy and a lot of experience that they bring to the table. But, we are trying to shift a little bit so that data becomes more involved and more a part of the decision processes and use the folks that typically in the past were the highest paid person in the room just making the decision.

We’ve now focused that a little differently and we are now using them to help us identify where we need to look and put some energy into changing things. We are actually right now in the process of redesigning our entire care management process in the organization. Within that, we are actually using a very data-driven approach to even design the program, which is certainly a step forward from where we’ve been in the past. It is allowing us to step away from some of the more traditional ways that you might design a care management program.

To hear more from Bob, please join us at Healthcare Data Insights, June 23-25 in Chicago. Register with the code XP1902BLOG and save $100 off the current rate. That is $300 in total savings if you register by this Friday, 5/23. REGISTER HERE!

Thursday, May 15, 2014

The 22nd Annual Medicaid Managed Congress is less than a week away, and this year will be the largest and best attended meeting to-date. With more attendees and companies attending than ever before, you can’t afford to miss the industry’s leading event. Reserve your seat today before time runs out…

The numbers don’t lie—based on this year’s turnout, your healthcare peers are ready to harness the new opportunities due to healthcare reform including Medicaid Expansion, exchanges, providing higher quality care, partnering with ACOs and more! Join us May 19-22 in Baltimore as we drive next generation Medicaid managed care alongside health plan and government heavyweights.

Wednesday, May 14, 2014

“Healthcare crisis,” “disparity” and “poverty” are popular words these days in American journalism and the blogosphere despite the recovering economy and the rocky implementation of the Accountable Care Act. A return to growth and expanded coverage should be good news. Poverty should be alleviated and health outcomes improving under such auspicious circumstances. What’s gone so wrong that it still gets the pundits so hot and bothered?

More Americans are enrolled in Medicaid than in any other point since its creation over forty years ago. Forty-two million have enrolled in managed care plans, 74.22% of beneficiaries–the highest percentage it has ever been (Medicaid Managed Care Enrollment Report). The increase in Medicaid beneficiaries is due to two main reasons:

1) The expansion of Medicaid services in 26 states to 138% of the federal poverty level; and
2) The dramatic increase in poverty and wage stagnation following the crippling financial crisis that started in 2007.

These patients range from the country’s most impoverished who are struggling to get by to lower-middle income earners who are fighting to stave off poverty as they float between Medicaid and health information exchange plans.

The increase of poverty and enrollment in Medicaid managed care is both boon and bane for Managed Care Organizations. Revenues will increase steadily as more beneficiaries elect their managed care plan. Unfortunately, the influx of new members, many of whom suffer disproportionately from issues related to the social determinants of health, will put pressure on existing healthcare infrastructure. These patient populations are more likely to suffer from insufficient food, substance abuse, and housing instability than other members and are less likely to have support when attempting to resolve these issues. This leads to an overutilization of services like emergency care at high cost with little gain.

Healthify helps MCOs deal with this critical issue by addressing their members’ social health needs. Our engineering team has developed a dynamic web-based screening tool to assess a member’s social and behavioral health risks at the point of care. Once our software identifies a members’ needs, it automatically connects them to our database of the best federal, state, and community programs that treat those needs. In a week’s time, we send out an interactive text message to see if they accessed the service and whether or not they found it useful. This end-to-end solution improves member referrals, satisfaction, and long-term health outcomes.

What truly makes Healthify’s software so robust are the tools that we offer the care team through our dashboard. We provide the care team with access to our resource database so they can continually update, modify, or add resources to better help their patients manage their needs. More importantly, however, the care team can see trends in their member population’s health through the dashboard and access individual records to send out and respond to messages. We use this as an ideal opportunity to measure patient engagement on behalf of the care team; it also gives them better lines of communication to interact with their case manager, further improving member satisfaction.

• Healthify’s service helps Medicaid managed care better manage the care of their members by addressing the social determinants of health;
• Our software platform helps care teams better care for members and help members more easily access services to help alleviate their needs; and
• We can reduce the cost of care per member per month by 2-6% while improving care quality and patient satisfaction.

Come and tell us what some of your members’ biggest social health risks are. We’ll be ready to help. In the meantime, check us out at www.healthify.us.

What are the unique challenges faced by states in Medicaid Managed Care Organizations?

Cindy:Significant challenges and quite unique. Number one, how do you engage this population in managing their healthcare? We talked a little bit about this already, but we’ve got unique patient characteristics – the prevalence of mental health, the health literacy, the difficulty navigating the system, the cultural sensitivities. So, we’ve got opportunities to figure out how to engage this population.

The challenge in managing their pharmaceutical care is that in this population, we lack two tools that are critical that we use on the commercial side that just don’t exist in the Medicaid space. Those being co-pays at a level that are significant enough to change behavior and mail order pharmacy – the home delivery pharmacies where we do a lot of utilization management using the pharmacists that are working in dispensing their mail order prescriptions. So, we’ve got to figure out that challenge of how to engage consumers with different tools unlike what we’ve used in the commercial market.

I think a challenge that the states and the Medicaid Managed Care Organizations are going to face is really predicting the costs. There are so many unknowns. What is this patient population’s pent up demand that we talked about? What is the impact of specialty pharmaceuticals going to be in this population? I think the predictive modeling and the analytics to assist states in Medicaid Managed Care Organizations is an essential skill set that is going to be needed as we navigate these new waters.

We talked about the access issue. There is going to be no access issue with pharmacies because you have probably have seen this in the press. There are actually more pharmacies than there are McDonald’s or Starbucks. If you just think about it, if you are looking at a pharmacy on this corner, there is probably a pharmacy on the other corner. So, access to pharmacies is not an issue, but access to physicians that we talked about is another unique challenge.

Then we are seeing in the press every day now issues with Medicaid reimbursement. So, even if we did have enough primary care physicians, the payment mechanisms for Medicaid, I think, is a challenge that will be unique state-by-state in Managed Medicaid Organizations.

I’d summarize this question by saying that the standardized PBM model just won’t work. These patients are unique. We talked about the challenges, but this need for a customized Medicaid strategy to deal with these unique needs is going to be absolutely essential to help the states and the Medicaid MCOs navigate these challenging waters for this Medicaid and subsidized exchange population.

Be empowered to do more with all of the data you already have at your fingertips. Regardless of what your role is—medical, sales/marketing, financial—data-driven decision-making will help put together smarter, better informed strategies. Attend HDI to learn how to implement data-informed programming.

HDI’s expert speaking faculty includes companies like Intermountain, CareSource, Steward Health Care Network, Molina and MDwise who are already deemed pioneers and masters of data-driven healthcare strategies, and will present case studies on how you can become a master as well!

Register by calling (888) 670-8200 to join us and mention code XP1902SAVE to buy one pass and get one free!

Healthcare Data Insights will take place in Chicago on June 23-25 at the Hilton Garden Inn Chicago Downtown. See you there.

The term ‘Revenue Leakage’ is used widely in the pharmaceutical industry and is creating management buzz! In Gross-to-Net the term most commonly references lost net sales as a result of unintentional internal or external data, process and system issues.

This webinar is to further explore the term Revenue Leakage and what it means to branded pharma, start-ups, generics, and biotechs. In Gross-to-Net, Revenue Leakage can arise in any customer segment (Government and Commercial) and any customer channel (Medicaid, VA, 340B, Managed Care, Specialty, Part D, etc.).

The key to mitigating Revenue Leakage is to recognize, assess and continuously improve. The industry has made large investments in adjudication systems and performed numerous audits to temper the hemorrhaging. There is no substitute to a strong cross-functional process with continuous analytics to ultimately control the risk.

Jennifer Sharpe from daVIZta, a Revenue Analytics firm, will moderate the Revenue Leakage discussion. Jennifer is joined by her fellow co-chairs for the upcoming IIR GTN conference in June: Larry Breen from Sunovion, Roxana Santiago from Hospira and Courtney Callihan from GSK.

The webinar addresses and provides insight on the following components of Revenue Leakage:

Collective Industry Definition

Customer Segment and Channel impacts

Financial Statement impacts (accruals, cash flow, forecasting)

The industry risk between adjudication and audit – the need for continuous improvement.

Industry best practices and next steps for mitigating risk and continuous improvement.

To hear more from Jennifer, Larry, Courtney, and Roxana, make sure you join them at the Gross-to-Net Accounting Forum, June 17-18 in Philadelphia, PA. Save $100 off the current rate when registering with the code: XP1911BLOG

Friday, May 9, 2014

This collaborative summit is designed to facilitate networking and integration between all key stakeholders in the evolving specialty pharmacy value chain, including the leading pharmaceutical manufacturers, health plans, and specialty pharmacies.

Thursday, May 8, 2014

THE authoritative MDRP event for everything government pricing, rebates, and regulation is back this September 15-17, 2014. IIR's 19th Annual Medicaid Drug Rebate Program Summit is the largest event in the space with the most speakers and government representations as well as 500+ MDRP executives ensuring you have the most comprehensive educational experience over three days.

Register now and take an extra $100off the current rate with Priority Code: XP1958BLOG

Year after year, MDRP Chicago continues to be THE industry event where you and your teams get essential regulatory updates from key federal and state government officials. 2014 highlights include:

MDRP Compliance and Medicare Part D Proposed rule updates from CMS

Annual Update on the 340B Program and 340B Mega Rule from HRSA

12th Annual States Dispute Resolution Meetings where you can realize millions in potential savings with 15 (and counting!) States

All new Legal & Compliance track and never before offered CLE credits for legal counsel

And more!

Plus, hear from our two industry keynotes share their first-hand experience in managing the true impact of the ACA and Medicaid reform:

Perry is talking with us today about a program that she works on as a part of the Camden Coalition of Healthcare Providers. What we’re hoping to do is get a general sense of what you and Jason are going to let folks know about at the Conference.

Why don’t you give me an overview of the program itself in terms of who the team members are, who the patients are, what the model is, where the care takes place – just kind of the basics of who, what and where.

Perry:Our program, is called the “Care Management Initiative”. What it is is a short-term – about 30-60 day intervention – that works with vulnerable patients in the Camden City area. Camden is a city in New Jersey, which definitely experiences – as does many cities across North America or a large population of people living in poverty. Many of these individuals also have complex medical problems, which sends them in and out of the hospital. What we do is target patients who utilize the hospital in the emergency room frequently. Our patients generally --- the eligibility to be on our panel is that they have to have at least two in-patient stays or emergency department visits within the past six months and one or two of several chronic conditions that we work with like diabetes, asthma, things of that nature. So, our care team is interdisciplinary. We have a social work, RN, LTMs and intervention specialists and health coaches – that’s my role – all on board to help coordinate the care of these patients. So, from the time that they are enrolled to the time that they graduate from the program, what we try to do is really help coordinate their care better across the board. Many of these patients are going in and out of the hospital because they don’t have the proper coordination between their different providers or just haven’t been to a primary care doctor in quite a long time. So, we help to reintegrate them into the healthcare system, get them connected to a primary care physician if they aren’t and also help connect them to other social services that will make it easier for them to take care of themselves – things like food delivery or food assistance if they need that, as well as connecting them to transportation, which is a big issue for many of our patients.

Tuesday, May 6, 2014

At the2nd Annual Gross-To-Net Accounting Forum, Miree Lee will be leading a workshop on theImpact of the MDRP AMP Final Rule on Accruals. With the CMS AMP Final Rule scheduled to be released in May, attendees of this workshop will learn about the many variables within the rule that alter government payer forecasting, gross-to-net and accrual calculations. Different types of manufacturers must also consider how their products and their distribution model are specifically impacted.Key considerations of the final rule, impact for each:

Pharmaceutical Price Points (AMP, BP, ASP, NFAMP, 340B, etc.)

Overview of Various Government Programs

Requirements under Medicaid Drug Rebate Program

What is AMP?

What are the inclusion and exclusion filters?

How is AMP used?

What is BP?

What are the inclusion and exclusion filters?

How is BP used?

What is the URA?

What are some potential changes in AMP, BP and URA?

How do companies accrue?

How does Medicaid expansion impact accruals?

Managed Care Medicaid and Duplicate Discounts

Other changes in Medicaid that may impact accruals

Q&A:

1. How feasible is collaboration between managed markets, commercial, government programs and Finance?

Collaboration takes on different forms for different companies. There isn't a "one size fits all" methodology except that the core principle of collaboration is a critical necessity for government pricing/program compliance. Some companies identify and memorialize the collaboration process via formal process methodology document which outlines the tactical activities of collaboration (e.g. roles, responsibilities, timelines, specific reports and data, meeting schedule, etc.). Other companies may adopt a less formal process whereby key persons of each department are involved in providing the proper information to the pricing department or responsible individual to ensure government pricing/program compliance. Depending upon the size, structure, product mix, complexity of business and various other factors, cross functional collaboration may look different company-to-company.

2. Key questions to ask before investing and building an automated GTN or GP system?

Number of products, number of NDCs, annual sales, number of direct and indirect customers, classes of trade for direct and indirect customers, number and types of discount contracts, rebate or chargeback, tiered or market share based contracts, volume based contracts, formulary status requirements, bundles, stacked discounts, types of fees - bona fide or not.

3. How to accrue and forecast patient/ payer related items? What critical/ essential information is required and what aspects you can’t afford to overlook.

Intimate knowledge of the competitive market

Shifts in market share and causes for the shifts (pricing, special contracts, supply, reimbursement)

On a bone-chilling day in January, Jennifer Turpin visited a wheelchair-bound patient named Olivia Richard at her small apartment in Boston. Turpin, a care coordinator, was conducting a home inspection for Richard, who had just joined One Care, a state program for low-income, chronically ill people who are dually eligible for Medicare and Medicaid.

Looking around the apartment, Turpin, who performs independent living assessments for the not-for-profit plan Commonwealth Care Alliance, was horrified at what she saw. Richard's sheets and dishes hadn't been washed in months, and her floor was black with dirt. Before she joined One Care, Richard did not receive consistent visits from home health aides.

“I didn't realize how bad the level of care I was getting was until that visit,” said Richard, who is 30. “If I were to get a sore on one of my legs and am lying on filthy sheets, I could get a life-threatening infection.”

Since late last year, 10 states have launched or are about to launch dual-eligible initiatives under the CMS' Financial Alignment Initiative to improve care for more than 9 million dual-eligibles by integrating Medicaid and Medicare benefits. They hope better care coordination will reduce costs for this very expensive population, currently totaling about $350 billion a year. It's estimated that about 2 million are eligible for the program in those 10 states.

But some experts question how many dual-eligible beneficiaries will voluntarily enroll in the newmanaged-care programs and whether private health plans participating in the demonstrations will get enough physicians and other providers to serve these challenging and time-consuming patients. In addition, there are questions about the quality of the plans themselves, and whether the demonstrations will produce cost savings.

While most dual-eligibles are 65 or older, around 40% are younger. Many duals under age 65 have multiple chronic health conditions, including mental-health and substance-abuse issues, or physical or developmental disabilities. Some are homeless, while others live in residential care facilities. Often the healthcare and other support services that they receive are fragmented because duals fall through the cracks of the two programs. Many duals need home- and community-based support in addition to medical and behavioral care.

While 26 states applied to participate, so far only California, Colorado, Illinois, Massachusetts, Minnesota, New York, Ohio, South Carolina, Virginia and Washington have received federal approval to start their programs. Massachusetts and Minnesota are the farthest along, having launched their programs last year. Illinois began enrollment in March, and the rest of the states are starting enrollment between April and October. Some states are targeting all their duals, while others are focusing on a subset, such as those under 65 or those needing long-term care.

“I'm glad they're moving slowly,” said Judy Feder, a Georgetown University professor of healthcare policy who has closely followed the duals demonstration. “Taking a large, fragile population and moving them into an untried new system is a gamble. Slow is better.”To continue reading this Modern Healthcare article, please click here.

I know you’ll be speaking at the 2014 Medicaid Managed Care Congress. So, hopefully this will give folks a little bit of a preview of what your talk is going to be like in Baltimore in May.

Tell us a little bit about the program itself, just the “who” in terms of the care providers, the patient profile, the “what” – the care model – and the “where” in terms of the care setting.

Dr. Gonzalez:Back when Medicaid Managed Care arrived in South Texas in March of 2012, we immediately saw a challenge with our most intense and high acuity psychiatric patients. When we did a financial analysis of those patients, we saw many readmissions to the same hospitals and a high utilization rate. In fact, out of our 20 most expensive and high-utilizing members, we found that more than half of them were psychiatric patients. Nevertheless, we decided that we had to do something about these high utilizers – very, very critical – so that they could live more independently in the community. In South Texas, there is a group called: “The Psych Nurse”. That’s the name of the company – The Psych Nurse Incorporated. They were traditionally a home-health psychiatric nurse provider for the Medicare product because in Texas, home health for psychiatry is not a covered benefit under Medicaid. So, it was a challenge and, internally at Cigna-HealthSpring, we needed to figure out how to engage the Psych Nurse because they have a very good reputation in the community and because they have a history of doing good work with the utilizing psychiatric patients. We felt we needed to take the opportunity to engage with the Psych Nurse to be partners and help us manage this population. So, what we did was engage the Psych Nurse and say: “I think you all have what it takes. Your model of looking at the entire person, looking at the health and looking at the well-being and the independence of the psychiatric patient instead of looking at a finite number of visits per patient is going to be the right approach.” So, it took several planning sessions and we finally came to an agreement with the Psych Nurse that we would send them our sickest and our highest utilizing, highest cost members. The framework of the program was kind of open. It was an open approach in that I would send them the name of a patient with a prior authorization for an extended amount of time – 99 visits. The Psych Nurse was then given free range to see those high-utilizing psychiatric patients as often as they thought they needed to see them – daily, every other day, seven times a week, ten times a week – whatever it took to help the patients live independently. Now, keep this in mind. This was not a hospitalization avoidance program. Many people like to slot this program into that kind of peg. That’s not what it was designed to do at all. The program is designed to help the patients to live independently out of jails, hospitals, nursing homes and live in their home or choice of homes out in the community. So, when the Psych Nurse engages one of these members, of course, like many psychiatric patients – and these are the sickest of the sick. These are the refractory schizophrenics, the non-compliant bipolar patients, the dual diagnosis patients with polysubstance abuse and other Axis I disorders. These are the patients who many, many have discarded, many have considered un-helpable and many have considered the drain on the system that no one can really fix. Well, as we engaged these members through the Psych Nurse and we had weekly rounds with me, the Medical Director and a Psychiatrist – I am a psychiatrist – we brainstormed plans, strategized how we’re going to help these members understand 1) their medication compliance, 2) their desire and hope and need for sobriety and 3) getting families involved as much as possible. I think the Psych Nurse is extremely skilled in getting these patients to understand their own health, their own need for continued and improved mental clarity and their families. South Texas, as you probably know, is heavily Hispanic. Mostly Mexican American. About 90% of the population is Mexican American and many of our patients only speak Spanish. The Psych Nurse is homegrown, pretty much. They are RNs – and that is the only type of nurse that we allow to see the patient. RNs – Registered nurses – who will bond with these patients in their culturally appropriate and culturally sensitive way. Some only speak Spanish. Well, our nurses only speak Spanish.